Outcomes of Single-Incision Laparoscopic Appendectomy at a Single Center

doi:10.4236/ss.2013.410083

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Surgical Science, 2013, 4, 426-428

http://dx.doi.org/10.4236/ss.2013.410083 Published Online October 2013 (http://www.scirp.org/journal/ss)

Outcomes of Single-Incision Laparoscopic Appendectomy

at a Single Center*

Takahiro Watanabe#, Hidetosi Wada, Masanori Sato, Yuichirou Miyaki, Junpei Tochikubo,

Norihiko Shiiya

Division of General Surgery and Endoscopic Surgery, Surgery I, Hamamatsu University School of Medicine, Hamamatsu, Japan

Email: #[email protected]

Received August 1, 2013; revised September 1, 2013; accepted September 9, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background and Objectives: Recently, single-incision laparoscopic surgery has been popular for minimally invasive

surgery and cosmetic improvement. We studied outcomes of single-incision laparoscopic appendectomy (SILA) in ac-

cordance with our strategy for acute appendicitis. Methods: Clinical outcomes were revealed in each of nine emergency

SILA (e-SILA) cases and eight interval SILA (i-SILA) cases performed for the treatment of acute appendicitis between

September 2010 and August 2012 at our hospital. Results: The male to female ratio was 6:3 for e-SILA and 5:3 for

i-SILA cases. Mean ages were 33.1 ± 17.8 years and 41 ± 21.6 years for e-SILA and i-SILA, respectively. The pre-

treatment white blood cell (WBC) count and C-reactive protein (CRP) levels were 14960 ± 4080/μL and 1.4 ± 2.3 mg/d,

respectively, for e-SILA and 12657 ± 4290/μL and 6.7 ± 8.3 mg/d, respectively, for i-SILA. The maximum transverse

diameter of appendix was 12.6 ± 3.5 mm for e-SILA and 11.6 ± 3.5 mm for i-SILA. Appendiceal abscesses were en-

countered in one (11%) e-SILA and three (38%) i-SILA cases. Perforation of the appendix at operation occurred in two

(22%) e-SILA cases and no i-SILA cases. Generalized peritonitis occurred in 4 (44%) e-SILA cases but in none of the

i-SILA cases. The postoperative hospital stay was 5.3 days for e-SILA, 2.7 days for i-SILA. Conversion to laparotomy

was not required in either group. One additional trocar was needed for an e-SILA case, and paralytic ileus occurred as a

postoperative complication in one e-SILA case. Conclusion: The outcomes of SILA performed under our strategy were

acceptable and useful without major postoperative complications.

Keywords: Laparoscopic Appendectomy; Single Access Laparoscopic Surgery; Minimally Invasive Surgery

1. Introduction

Since the initial report by Semm on laparoscopic appen-

dectomy in 1983 [1], the procedure has been widely per-

formed worldwide. Recently, single-incision laparo-

scopic appendectomy (SILA) has been increasingly per-

formed in many surgical centers. In Japan, the cases of

single-incision laparoscopic surgery have been increasing

since 2000; we have employed SILA for the treatment of

acute appendicitis since September 2010 in our hospital.

In this study, we aimed to reveal outcomes of SILA in

accordance with our strategy for acute appendicitis.

2. Materials and Methods

From September 2010 to August 2012, we performed 17

SILA procedures at Hamamatsu University School of

Medicine. These included nine emergency SILA (e-SILA)

and eight interval SILA (i-SILA) cases. We revealed the

clinical outcomes each of e-SILA and i-SILA.

Our treatment strategy for acute appendicitis is de-

picted in Figure 1. We performed e-SILA in cases of

generalized peritonitis and those with likely perforated

appendicitis such as a markedly swollen appendix, thin-

ning of the appendix wall and impacted appendiceal cal-

culi. Andi-SILA was adopted to avoid extended opera-

tions, such as ileocecal resections, and to decrease post-

*Disclosure of interest: We report no conflict of interest.

#Corresponding author. Figure 1. Our strategy of treatment for acute appendicitis.

T. WATANABE ET AL. 427

operative complications. We followed a conservative

treatment for cases of local peritonitis, appendiceal ab-

scesses, and spread of inflammation around the appen-

dix. In cases requiring an interval appendectomy in order

to avoid recurrent appendicitis following conservative

therapy, i-SILA was performed a few months later. Pa-

tients selected e-SILA or i-SILA if they had mild in-

flammatory appendicitis along with the absence of

aforementioned signs or symptoms.

Operation was performed using a 1.5 - 2.0 cm tran-

sumbilical vertical incision. Thereafter, the fascia and the

peritoneum were opened vertically, and three 5-mm tro-

cars were inserted into the abdomen for introduction of

endoscopic instruments. Carbon dioxide was used to in-

flate the abdomen at 8 - 10 mmHg pressure. The operator

used two 5-mm forceps, and the first assistant manned a

30˚ 5-mm laparoscope (KarlStorz, Tuttlingen, Germany).

The mesoappendix and appendicular vessel was dis-

sected using laparoscopic coagulating shears. Once the

cecum was mobilized to the umbilicus, the appendix was

excised and removed via the transumbilical incision in all

cases. A first or second generation cephalosporin antibi-

otic was administered only on the day of surgery in most

cases ofi-SILA cases. Conversely, antibiotics such as

second generation cephalosporin, tazobactam sodium/

piperacillin sodium and carbapenem were administered

for an average of 4.4 days in e-SILA cases at the sur-

geon’s discretion.

3. Results

The male to female ratio was 6:3 for e-SILA and 5:3 for

i-SILA cases. Mean ages were 33.1 ± 17.8 years and 41 ±

21.6 years for e-SILA and i-SILA, respectively. In addi-

tion, the pretreatment white blood cell (WBC) count and

C-reactive protein (CRP) levels were 14960 ± 4080/μL

and 1.4 ± 2.3 mg/d, respectively, for e-SILA and 12657 ±

4290/μL and 6.7 ± 8.3 mg/d, respectively, for i-SILA.

Moreover, the maximum transverse diameter of appendix

as measured by computed tomography was 12.6 ± 3.5

mm for e-SILA and 11.6 ± 3.5 mm for i-SILA. Appen-

diceal abscesses were encountered in one (11%) e-SILA

and three (38%) i-SILA cases. Perforation of the appen-

dix at operation occurred in two (22%) e-SILA cases and

no i-SILA cases. Generalized peritonitis occurred in 4

(44%) e-SILA cases but none of the i-SILA cases. The

number of cases with appendiceal calculi totaled 7 (78%)

for e-SILA and 2 (25%) for i-SILA (Table 1).

One additional trocar was used in a case of e-SILA

with severe inflammation; however, no additional trocars

were required in any of the i-SILA cases, and none of the

cases in either group were converted to laparotomy. The

operation times were 97 ± 38 min for e-SILA and 78 ±

32 min for i-SILA. Average blood loss was 5 ± 8 ml for

e-SILA and 2 ± 4 ml for i-SILA. The postoperative com-

plication of paralytic ileus developed in only one e-SILA

case, and the patient recovered with conservative man-

agement. No other postoperative complications, includ-

ing wound infections, were encountered. The postopera-

tive length of hospital stay was 2.7 ± 1.0 days (range, 2 -

5 days) for patients undergoing i-SILA and 5.3 ± 3.1

days (range, 2 - 12 days) for patients undergoing e-SILA

(Table 2).

4. Discussion

Since the first laparoscopic appendectomy was reported,

the procedure has been extensively performed worldwide.

Compared with open appendectomy, laparoscopic ap-

pendectomy has the benefits of a small incision size, less

postoperative pain, decreased postoperative complica-

tions, shorter hospital stay, and improved cosmesis [2-4].

In Japan, single-incision laparoscopic surgery was re-

ported for the first time in 2000, and the number of cases

undergoing this procedure has continued to increase since

Table 1. Characteristics of patients.

e-SILA i-SILA

Number of case 9 8

Male:Female 6:3 5:3

Age (years) 33.1 ± 17.8 41 ± 21.6

Original WBC (/μL) 14960 ± 4080 12657 ± 4290

Original CRP (mg/d) 1.4 ± 2.3 6.7 ± 8.3

Size of the appendix* (mm)12.6 ± 3.5 11.6 ± 3.5

Appendiceal calculi** 7 (78%) 2 (25%)

Appendiceal abscess 1 (11%) 3 (38%)

Perforation of the appendix2 (22%) 0

Generalized peritonitis 4 (44%) 0

WBC: White blood cell; CRP: C-reactive protein; SILA: single-incision

laparoscopic appendectomy; e-: emergency; i-: interval; *Measuring the

diameter of the appendix on the CT examination; **Appendiceal calculi that

can be identified on the CT examination.

Table 2. Outcomes of e-SILA and i-SILA.

e-SILA i-SILA

Additional ports 1 (11%) 0

Conversion to laparotomy 0 0

Operation time (min) 97 ± 38 78 ± 3

Blood loss (ml) 5 ± 8 2 ± 4

Postoperative complication1 (paralytic ileus) 0

Postoperative length of stay5.3 ± 3.1 2.7 ± 1.0

SILA: single-incision laparoscopic appendectomy.

T. WATANABE ET AL.

428

2008. The purpose of this research was to reveal out-

comes of SILA in accordance with the specific strategy

used at our hospital. Then, our result was acceptable

without major postoperative complications.

There are differences in strategies for acute appendici-

tis in each hospital. Surgical site infection (SSI) is the

most common complication after appendectomy. Mar-

genthaler et al. [5] reported the incidence of SSI after

appendectomy to be approximately 8%. It is essential to

reduce the incidence of SSI for improving the outcome

following appendicitis. In previous reports [6-8], a

wound infection rate of about 5% for single-incision ap-

pendectomies has been described, which was higher than

conventional laparoscopic appendectomy. In our study,

however, wound infection was not encountered. Appro-

priate surgical practices such as gentle manipulation and

adequate wound protection are essential to prevent SSI.

Our operation time for SILA was longer than that re-

ported in previous studies [9,10]. One reason for this

discrepancy may be our surgical technique. We per-

formed extracorporeal appendectomies through a single

umbilical incision after the cecum was mobilized to the

umbilicus, if necessary. The merit of this method is that

when appendiceal calculi are impacted at the appendiceal

base, we can easily manage this situation under direct

vision. However, Kang et al. [10] reported the impor-

tance of selecting intra- or extracorporeal appendectomy

whether the cecum is mobile or not in order to avoid un-

necessary manipulation and reduce operation time.

A total of 20 cases underwent conservative treatment

for acute appendicitis at our hospital from September

2010 to August 2012. Two cases (10%) were converted

to e-SILA because of severe inflammation, 8 cases (40%)

underwent i-SILA, and 10 cases (50%) did not undergo

any operation. At the discretion of the attending physi-

cian, antibiotics such as second generation cephalosporin,

tazobactam sodium/piperacillin sodium, and carbapenem

were administered for an average of 5.4 days as our con-

servative treatment. The hospital stay during conserva-

tive treatment averaged 7.3 days (range, 4 - 20), and the

outcomes were acceptable. As i-SILA was performed

after the inflammation subsided, under our treatment

regimen, patients in this group were able to be dis-

charged considerably earlier compared with those in the

e-SILA group.

5. Conclusion

In conclusion, the outcomes of SILA performed under

our strategy were acceptable and useful without major

postoperative complications.

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